2017 Kaiser Permanente Medicare Plus High w/Part D (AB) (Cost) Formulary



Below is the Formulary, or drug list, for Kaiser Permanente Medicare Plus High w/Part D (AB) (Cost) from Kaiser Fndn Hp Of The Mid-atlantic Sts This formulary is a list of prescription medications that are covered under Kaiser Fndn Hp Of The Mid-atlantic Sts's 2017 Medicare Advantage Plan. The Kaiser Permanente Medicare Plus High w/Part D (AB) (Cost) plan has a $0 drug deductible. The Initial Coverage Limit (ICL) for this plan is $3700. The Initial Coverage Period is the period after the Deductible has been met but before the Coverage Gap phase. Once you and your plan provider have spent $3700 on covered drugs. (combined amount plus your deductible) You will enter the coverage gap. (AKA "donut hole") Once you reach the coverage gap you will be required to pay 45% of the plan's cost for covered brand-name prescription drugs unless your plan offers additional coverage. You can see if this plan offers coverage in the "donut hole" be clicking the "Coverage Gap" link on the left above the chart. In 2017 if you have spent $4700 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. Kaiser Permanente Medicare Plus High w/Part D (AB) (Cost) will begin paying approximately 95% of your covered medication expenses. You can see if this plan covers your drugs in the Catastrophic Phase by clicking the "Catastrophic" link on the left above the chart.

See More on Kaiser Permanente Medicare Plus High w/Part D (AB) (Cost)





Plan Name:
Kaiser Permanente Medicare Plus High w/Part D (AB) (Cost)
Plan ID:
H2150-002
Provider: Kaiser Fndn Hp Of The Mid-atlantic Sts
Plan Year:2017
Premium:$103.00
Deductible:$0
Initial Coverage Limit:$3700
Coverage Area:District of Columbia




Current Table info:


Coverage Level:
Initial Coverage
Days Supply:
30 Days
Drugs Starting With Letter: T

Change Table Options:


Drugs Starting Letter:
A  B  C  D  E  F  G  H  I  J  K  L  M  N  O  P  Q  R  S  U  V  W  X  Y  Z 
Coverage Level:
Drug Days Pricing:60 Day
90 Day











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Drug Name Drug Strength Units in Package Tier Level Amount Limit Days Limit Prior Authorization
Y/N
Step Therapy
Y/N
Cost Preferred Max Cost Non Preferred Max Cost Mail Max
Tabloid 40mg 1 Bottle In 1 Carton > 25 Tablet In 1 Bottle
3
N N $42N$47N$42N
Taclonex .5; 50mg/g; ug/g 100 Carton In 1 Case > 1 Tube In 1 Carton > 60 G In 1 Tube
5
N N 33%N33%N33%N
Taclonex .5; 50mg/g; ug/g 40 Carton In 1 Case > 1 Bottle In 1 Carton > 60 G In 1 Bottle
4
N N $80N$100N$80N
Tacrolimus 1 Tube In 1 Carton > 30 G In 1 Tube
2
N N $15N$20N$15N
Tacrolimus 1 Tube In 1 Carton > 30 G In 1 Tube
2
N N $15N$20N$15N
Tacrolimus .5mg 100 Capsule In 1 Bottle
2
Y N $15N$20N$15N
Tacrolimus 1mg 100 Capsule In 1 Bottle
2
Y N $15N$20N$15N
Tacrolimus 5mg 100 Capsule In 1 Bottle
2
Y N $15N$20N$15N
Talwin 30mg/mL 1 Vial, Multi-dose In 1 Carton > 10 Ml In 1 Vial, Multi-dose
4
N N $80N$100N$80N
Tamiflu 75mg 1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
3
N N $42N$47N$42N
Tamiflu 45mg 1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
3
N N $42N$47N$42N
Tamiflu 30mg 1 Blister Pack In 1 Carton > 10 Capsule In 1 Blister Pack
3
N N $42N$47N$42N
Tamiflu 6mg/mL 1 Bottle, Glass In 1 Carton > 60 Ml In 1 Bottle, Glass
3
N N $42N$47N$42N
Tamoxifen Citrate 10mg 180 Tablet, Film Coated In 1 Bottle
2
N N $15N$20N$15N
Tamoxifen Citrate 20mg 30 Tablet In 1 Bottle
2
N N $15N$20N$15N
Tamsulosin Hydrochloride 100 Capsule In 1 Bottle
2
N N $15N$20N$15N
Tanzeum 30mg/.5mL 4 Syringe In 1 Carton > .5 Ml In 1 Syringe
4
N N $80N$100N$80N
Tanzeum 50mg/.5mL 4 Syringe In 1 Carton > .5 Ml In 1 Syringe
4
N N $80N$100N$80N
Tapazole 5mg 100 Tablet In 1 Bottle
2
N N $15N$20N$15N
Tapazole 10mg 100 Tablet In 1 Bottle
2
N N $15N$20N$15N
Tarceva 25mg 30 Tablet In 1 Bottle
5
N N 33%N33%N33%N
Tarceva 100mg 30 Tablet In 1 Bottle
5
N N 33%N33%N33%N
Tarceva 150mg 30 Tablet In 1 Bottle
5
N N 33%N33%N33%N
Targretin 60 G In 1 Tube
3
N N $42N$47N$42N
Targretin 75mg 1 Bottle In 1 Carton > 100 Capsule, Liquid Filled In 1 Bottle
5
N N 33%N33%N33%N
Tarina Fe 1/20 3 Pouch In 1 Carton > 1 Kit In 1 Pouch
2
N N $15N$20N$15N
Tarka 2; 180mg/1; mg 100 Tablet, Film Coated, Extended Release In 1 Bottle
4
N N $80N$100N$80N
Tarka 1; 240mg/1; mg 100 Tablet, Film Coated, Extended Release In 1 Bottle
4
N N $80N$100N$80N
Tarka 2; 240mg/1; mg 100 Tablet, Film Coated, Extended Release In 1 Bottle
4
N N $80N$100N$80N
Tarka 4; 240mg/1; mg 100 Tablet, Film Coated, Extended Release In 1 Bottle
4
N N $80N$100N$80N
Tasigna 200mg 28 Capsule In 1 Blister Pack
5
N N 33%N33%N33%N
Tasigna 150mg 4 Blister Pack In 1 Carton > 28 Capsule In 1 Blister Pack
5
N N 33%N33%N33%N
Tasmar 100mg 90 Tablet, Film Coated In 1 Bottle
4
N N $80N$100N$80N
Taxotere 80mg/4mL 1 Vial, Glass In 1 Carton > 4 Ml In 1 Vial, Glass
4
N N $80N$100N$80N
Tazicef 25 Vial In 1 Tray > 1 Injection, Powder, For Solution In 1 Vial
2
N N $15N$20N$15N
Tazicef 10 Vial In 1 Tray > 1 Injection, Powder, For Solution In 1 Vial
2
N N $15N$20N$15N
Tazicef 10 Vial, Pharmacy Bulk Package In 1 Carton > 1 Injection, Powder, For Solution In 1 Vial, Pharmacy Bulk Package
2
N N $15N$20N$15N
Tazorac 1mg/g 1 Tube In 1 Carton > 100 G In 1 Tube
3
Y N $42N$47N$42N
Tazorac .5mg/g 1 Tube In 1 Carton > 100 G In 1 Tube
3
Y N $42N$47N$42N
Tazorac .5mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
3
Y N $42N$47N$42N
Tazorac 1mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
3
Y N $42N$47N$42N
Taztia 120mg 90 Capsule, Extended Release In 1 Bottle, Plastic
2
N N $15N$20N$15N
Taztia 180mg 90 Capsule, Extended Release In 1 Bottle, Plastic
2
N N $15N$20N$15N
Taztia 240mg 90 Capsule, Extended Release In 1 Bottle, Plastic
2
N N $15N$20N$15N
Taztia 300mg 90 Capsule, Extended Release In 1 Bottle, Plastic
2
N N $15N$20N$15N
Taztia 360mg 90 Capsule, Extended Release In 1 Bottle, Plastic
2
N N $15N$20N$15N
Tecfidera 120mg 1 Bottle, Plastic In 1 Carton > 14 Capsule In 1 Bottle, Plastic
5
N N 33%N33%N33%N
Tecfidera 240mg 1 Bottle, Plastic In 1 Carton > 60 Capsule In 1 Bottle, Plastic
5
N N 33%N33%N33%N
Tecfidera 1 Kit In 1 Kit * 14 Capsule In 1 Bottle, Plastic * 46 Capsule In 1 Bottle, Plastic
5
N N 33%N33%N33%N
Teflaro 400mg/20mL 10 Vial, Single-dose In 1 Carton
4
N N $80N$100N$80N
Teflaro 600mg/20mL 10 Vial, Single-dose In 1 Carton
4
N N $80N$100N$80N
Tegretol 100mg/5mL 450 Ml In 1 Bottle
4
N N $80N$100N$80N
Tegretol 200mg 100 Tablet In 1 Bottle
4
N N $80N$100N$80N
Tegretol 100mg 100 Tablet, Extended Release In 1 Bottle
4
N N $80N$100N$80N
Tegretol 200mg 100 Tablet, Extended Release In 1 Bottle
4
N N $80N$100N$80N
Tegretol 400mg 100 Tablet, Extended Release In 1 Bottle
4
N N $80N$100N$80N
Tekturna 150mg 30 Tablet, Film Coated In 1 Bottle
4
N N $80N$100N$80N
Tekturna 300mg 30 Tablet, Film Coated In 1 Bottle
4
N N $80N$100N$80N
Tekturna Hct 150; 12.5mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N $80N$100N$80N
Tekturna Hct 150; 25mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N $80N$100N$80N
Tekturna Hct 300; 12.5mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N $80N$100N$80N
Tekturna Hct 300; 25mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N $80N$100N$80N
Telmisartan 20mg 3 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
2
N N $15N$20N$15N
Telmisartan 40mg 3 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
2
N N $15N$20N$15N
Telmisartan 80mg 3 Blister Pack In 1 Carton > 10 Tablet In 1 Blister Pack
2
N N $15N$20N$15N
Telmisartan And Amlodipine 5; 40mg/1; mg 30 Tablet In 1 Bottle
2
N N $15N$20N$15N
Telmisartan And Amlodipine 10; 40mg/1; mg 30 Tablet In 1 Bottle
2
N N $15N$20N$15N
Telmisartan And Amlodipine 5; 80mg/1; mg 30 Tablet In 1 Bottle
2
N N $15N$20N$15N
Telmisartan And Amlodipine 10; 80mg/1; mg 30 Tablet In 1 Bottle
2
N N $15N$20N$15N
Telmisartan And Hydrochlorothiazide 90 Tablet In 1 Bottle
2
N N $15N$20N$15N
Telmisartan And Hydrochlorothiazide 90 Tablet In 1 Bottle
2
N N $15N$20N$15N
Telmisartan And Hydrochlorothiazide 90 Tablet In 1 Bottle
2
N N $15N$20N$15N
Temazepam 7.5mg 100 Capsule In 1 Bottle, Plastic
2
N N $15N$20N$15N
Temazepam 22.5mg 30 Capsule In 1 Bottle, Plastic
2
N N $15N$20N$15N
Temazepam 15mg 100 Blister Pack In 1 Box, Unit-dose
2
N N $15N$20N$15N
Temazepam 30mg 500 Capsule In 1 Bottle
2
N N $15N$20N$15N
Temovate .5mg/g 1 Tube In 1 Carton > 30 G In 1 Tube
2
N N $15N$20N$15N
Tencon 100 Tablet In 1 Bottle, Plastic
2
N N $15N$20N$15N
Tenex 1mg 500 Tablet In 1 Bottle, Plastic
4
N N $80N$100N$80N
Tenex 2mg 100 Tablet In 1 Bottle, Plastic
4
N N $80N$100N$80N
Tenivac 10 Syringe In 1 Package > .5 Ml In 1 Syringe
6
N N $0N$0NNAN
Terazol 3 1 Tube, With Applicator In 1 Carton > 20 G In 1 Tube, With Applicator
4
N N $80N$100N$80N
Terazol 7 1 Tube, With Applicator In 1 Carton > 45 G In 1 Tube, With Applicator
4
N N $80N$100N$80N
Terazosin 1mg 100 Capsule In 1 Bottle
2
N N $15N$20N$15N
Terazosin Hydrochloride 2mg 100 Capsule In 1 Bottle
2
N N $15N$20N$15N
Terazosin Hydrochloride 5mg 100 Capsule In 1 Bottle
2
N N $15N$20N$15N
Terazosin Hydrochloride 10mg 100 Capsule In 1 Bottle
2
N N $15N$20N$15N
Terbinafine Hydrochloride 90 Tablet In 1 Bottle
2
N N $15N$20N$15N
Terbutaline Sulfate 2.5mg 100 Tablet In 1 Bottle
2
N N $15N$20N$15N
Terbutaline Sulfate 5mg 100 Tablet In 1 Bottle
2
N N $15N$20N$15N
Terbutaline Sulfate 1mg/mL 25 Vial, Single-use In 1 Tray > 1 Ml In 1 Vial, Single-use
2
N N $15N$20N$15N
Terconazole 80mg 1 Blister Pack In 1 Carton > 3 Suppository In 1 Blister Pack
2
N N $15N$20N$15N
Terconazole 8mg/g 1 Tube, With Applicator In 1 Carton > 20 G In 1 Tube, With Applicator
2
N N $15N$20N$15N
Terconazole 4mg/g 1 Tube, With Applicator In 1 Carton > 45 G In 1 Tube, With Applicator
2
N N $15N$20N$15N
Testim 50mg/5g 30 Tube In 1 Carton > 5 G In 1 Tube
4
N N $80N$100N$80N
Testosterone 1 Canister In 1 Carton > 60 G In 1 Canister
2
N N $15N$20N$15N
Testosterone 30 Packet In 1 Carton
2
N N $15N$20N$15N
Testosterone Cypionate 1 Vial, Multi-dose In 1 Carton > 10 Ml In 1 Vial, Multi-dose
2
N N $15N$20N$15N
Testosterone Cypionate 1 Vial, Multi-dose In 1 Carton > 10 Ml In 1 Vial, Multi-dose
2
N N $15N$20N$15N
Testosterone Enanthate 200mg/mL 1 Vial, Multi-dose In 1 Carton > 5 Ml In 1 Vial, Multi-dose
2
N N $15N$20N$15N
Tetracycline Hydrochloride 250mg 100 Capsule In 1 Bottle
4
N N $80N$100N$80N
Tetracycline Hydrochloride 500mg 100 Capsule In 1 Bottle
4
N N $80N$100N$80N
Thalomid 50mg 10 Blister Pack In 1 Box
5
N N 33%N33%N33%N
Thalomid 100mg 5 Blister Pack In 1 Box
5
N N 33%N33%N33%N
Thalomid 150mg 4 Blister Pack In 1 Box
5
N N 33%N33%N33%N
Thalomid 200mg 3 Blister Pack In 1 Box
5
N N 33%N33%N33%N
Theophylline 400mg 100 Tablet, Extended Release In 1 Bottle, Plastic
2
N N $15N$20N$15N
Theophylline 600mg 100 Tablet, Extended Release In 1 Bottle, Plastic
2
N N $15N$20N$15N
Theophylline 300mg 100 Tablet, Extended Release In 1 Bottle
2
N N $15N$20N$15N
Theophylline 200mg 500 Tablet, Extended Release In 1 Bottle
2
N N $15N$20N$15N
Theophylline 100mg 500 Tablet, Extended Release In 1 Bottle
2
N N $15N$20N$15N
Theophylline 450mg 100 Tablet, Extended Release In 1 Bottle
2
N N $15N$20N$15N
Theophylline 80mg/15mL 473 Ml In 1 Bottle, Plastic
2
N N $15N$20N$15N
Thiola 100mg 100 Tablet, Sugar Coated In 1 Bottle
4
N N $80N$100N$80N
Thioridazine Hydrochloride 100mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N $15N$20N$15N
Thioridazine Hydrochloride 50mg 100 Blister Pack In 1 Box, Unit-dose
2
N N $15N$20N$15N
Thioridazine Hydrochloride 10mg 1000 Tablet, Film Coated In 1 Bottle, Plastic
2
N N $15N$20N$15N
Thioridazine Hydrochloride 25mg 1000 Tablet, Film Coated In 1 Bottle, Plastic
2
N N $15N$20N$15N
Thiothixene 2mg 100 Capsule In 1 Bottle, Plastic
2
N N $15N$20N$15N
Thiothixene 5mg 100 Capsule In 1 Bottle, Plastic
2
N N $15N$20N$15N
Thiothixene 10mg 100 Capsule In 1 Bottle, Plastic
2
N N $15N$20N$15N
Thiothixene 1mg 100 Capsule In 1 Bottle
2
N N $15N$20N$15N
Thymoglobulin 5mg/mL 5 Ml In 1 Vial, Glass
4
N N $80N$100N$80N
Thyrolar 12.5; 3.1ug/1; ug 100 Tablet In 1 Bottle
4
N N $80N$100N$80N
Thyrolar 25; 6.25ug/1; ug 100 Tablet In 1 Bottle
4
N N $80N$100N$80N
Thyrolar 50; 12.5ug/1; ug 100 Tablet In 1 Bottle
4
N N $80N$100N$80N
Thyrolar 100; 25ug/1; ug 100 Tablet In 1 Bottle
4
N N $80N$100N$80N
Thyrolar 150; 37.5ug/1; ug 100 Tablet In 1 Bottle
4
N N $80N$100N$80N
Tiagabine Hydrochloride 2mg 30 Tablet, Film Coated In 1 Bottle
2
N N $15N$20N$15N
Tiagabine Hydrochloride 4mg 30 Tablet, Film Coated In 1 Bottle
2
N N $15N$20N$15N
Tiazac 90 Capsule, Extended Release In 1 Bottle, Plastic
4
N N $80N$100N$80N
Tiazac 90 Capsule, Extended Release In 1 Bottle, Plastic
4
N N $80N$100N$80N
Tiazac 90 Capsule, Extended Release In 1 Bottle, Plastic
4
N N $80N$100N$80N
Tiazac 90 Capsule, Extended Release In 1 Bottle, Plastic
4
N N $80N$100N$80N
Tiazac 90 Capsule, Extended Release In 1 Bottle, Plastic
4
N N $80N$100N$80N
Tiazac 90 Capsule, Extended Release In 1 Bottle, Plastic
4
N N $80N$100N$80N
Tigan 25 Vial, Single-dose In 1 Tray > 2 Ml In 1 Vial, Single-dose
4
N N $80N$100N$80N
Tigan 300mg 100 Capsule In 1 Bottle
4
Y N $80N$100N$80N
Tikosyn .125mg 60 Capsule In 1 Bottle
4
N N $80N$100N$80N
Tikosyn .25mg 60 Capsule In 1 Bottle
4
N N $80N$100N$80N
Tikosyn .5mg 60 Capsule In 1 Bottle
4
N N $80N$100N$80N
Timolol Maleate 5mg 100 Tablet In 1 Bottle, Plastic
2
N N $15N$20N$15N
Timolol Maleate 10mg 100 Tablet In 1 Bottle, Plastic
2
N N $15N$20N$15N
Timolol Maleate 20mg 100 Tablet In 1 Bottle, Plastic
2
N N $15N$20N$15N
Timolol Maleate 3.4mg/mL 1 Bottle, Dispensing In 1 Carton > 5 Ml In 1 Bottle, Dispensing
2
N N $15N$20N$15N
Timolol Maleate 6.8mg/mL 1 Bottle, Dispensing In 1 Carton > 5 Ml In 1 Bottle, Dispensing
2
N N $15N$20N$15N
Timolol Maleate 2.5mg/mL 15 Ml In 1 Bottle, Plastic
2
N N $15N$20N$15N
Timolol Maleate 5mg/mL 10 Ml In 1 Bottle, Plastic
2
N N $15N$20N$15N
Timoptic-xe 2.5mg/mL 1 Bottle, Dispensing In 1 Carton > 5 Ml In 1 Bottle, Dispensing
4
N N $80N$100N$80N
Timoptic-xe 5mg/mL 1 Bottle, Dispensing In 1 Carton > 5 Ml In 1 Bottle, Dispensing
4
N N $80N$100N$80N
Tindamax 20 Tablet, Film Coated In 1 Bottle
4
N N $80N$100N$80N
Tinidazole 250mg 40 Tablet In 1 Bottle
2
N N $15N$20N$15N
Tinidazole 500mg 60 Tablet In 1 Bottle
2
N N $15N$20N$15N
Tirosint 13ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N $80N$100N$80N
Tirosint 25ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N $80N$100N$80N
Tirosint 50ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N $80N$100N$80N
Tirosint 75ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N $80N$100N$80N
Tirosint 88ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N $80N$100N$80N
Tirosint 100ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N $80N$100N$80N
Tirosint 112ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N $80N$100N$80N
Tirosint 125ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N $80N$100N$80N
Tirosint 137ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N $80N$100N$80N
Tirosint 150ug 4 Blister Pack In 1 Carton > 7 Capsule In 1 Blister Pack
4
N N $80N$100N$80N
Tivicay 50mg 30 Tablet, Film Coated In 1 Bottle
3
N N $42N$47N$42N
Tivorbex 90 Capsule In 1 Bottle
4
N N $80N$100N$80N
Tivorbex 90 Capsule In 1 Bottle
4
N N $80N$100N$80N
Tizanidine 2mg 150 Tablet In 1 Bottle, Plastic
2
N N $15N$20N$15N
Tizanidine 4mg 1000 Tablet In 1 Bottle
2
N N $15N$20N$15N
Tizanidine Hydrochloride 2mg 150 Capsule, Gelatin Coated In 1 Bottle
2
N N $15N$20N$15N
Tizanidine Hydrochloride 4mg 150 Capsule, Gelatin Coated In 1 Bottle
2
N N $15N$20N$15N
Tizanidine Hydrochloride 6mg 150 Capsule, Gelatin Coated In 1 Bottle
2
N N $15N$20N$15N
Tobi 300mg/5mL 56 Pouch In 1 Carton
5
Y N 33%N33%N33%N
Tobi Podhaler 28mg 224 Package In 1 Box, Unit-dose
5
N N 33%N33%N33%N
Tobradex 1; 3mg/mL; mg/mL 5 Ml In 1 Bottle, Plastic
4
N N $80N$100N$80N
Tobradex 1; 3mg/g; mg/g 3.5 G In 1 Tube
3
N N $42N$47N$42N
Tobradex St .5; 3mg/mL; mg/mL 5 Ml In 1 Bottle
4
N N $80N$100N$80N
Tobramycin 300mg/5mL 56 Ampule In 1 Carton > 5 Ml In 1 Ampule
2
Y N $15N$20N$15N
Tobramycin 10mg/mL 25 Vial, Multi-dose In 1 Tray > 2 Ml In 1 Vial, Multi-dose
2
N N $15N$20N$15N
Tobramycin 40mg/mL 25 Vial, Multi-dose In 1 Tray > 2 Ml In 1 Vial, Multi-dose
2
N N $15N$20N$15N
Tobramycin 3mg/mL 1 Bottle, Dropper In 1 Carton > 5 Ml In 1 Bottle, Dropper
2
N N $15N$20N$15N
Tobramycin And Dexamethasone 1; 3mg/mL; mg/mL 1 Bottle, Dropper In 1 Carton > 5 Ml In 1 Bottle, Dropper
2
N N $15N$20N$15N
Tobrex 3mg/mL 5 Ml In 1 Bottle, Plastic
4
N N $80N$100N$80N
Tobrex 3mg/g 3.5 G In 1 Tube
3
N N $42N$47N$42N
Tofranil 10mg 30 Tablet, Sugar Coated In 1 Bottle
2
N N $15N$20N$15N
Tofranil 25mg 30 Tablet, Sugar Coated In 1 Bottle
2
N N $15N$20N$15N
Tofranil 50mg 30 Tablet, Sugar Coated In 1 Bottle
2
N N $15N$20N$15N
Tolazamide 250mg 100 Tablet In 1 Bottle, Plastic
2
N N $15N$20N$15N
Tolazamide 500mg 100 Tablet In 1 Bottle, Plastic
2
N N $15N$20N$15N
Tolbutamide 500mg 500 Tablet In 1 Bottle, Plastic
2
N N $15N$20N$15N
Tolmetin Sodium 400mg 100 Capsule In 1 Bottle
2
N N $15N$20N$15N
Tolmetin Sodium 600mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N $15N$20N$15N
Tolterodine Tartrate 2mg 30 Capsule, Extended Release In 1 Bottle, Plastic
2
N N $15N$20N$15N
Tolterodine Tartrate 500 Capsule, Extended Release In 1 Bottle, Plastic
2
N N $15N$20N$15N
Tolterodine Tartrate 2mg 60 Tablet, Film Coated In 1 Bottle, Plastic
2
N N $15N$20N$15N
Tolterodine Tartrate 1mg 500 Tablet, Film Coated In 1 Bottle
2
N N $15N$20N$15N
Topamax 25mg 60 Tablet, Coated In 1 Bottle
4
N N $80N$100N$80N
Topamax 50mg 60 Tablet, Coated In 1 Bottle
4
N N $80N$100N$80N
Topamax 100mg 60 Tablet, Coated In 1 Bottle
4
N N $80N$100N$80N
Topamax 200mg 60 Tablet, Coated In 1 Bottle
4
N N $80N$100N$80N
Topamax 25mg 60 Capsule, Coated Pellets In 1 Bottle
4
N N $80N$100N$80N
Topamax 15mg 60 Capsule, Coated Pellets In 1 Bottle
4
N N $80N$100N$80N
Topicort .5mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
2
N N $15N$20N$15N
Topicort 2.5mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
2
N N $15N$20N$15N
Topicort 2.5mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
2
N N $15N$20N$15N
Topicort .5mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
2
N N $15N$20N$15N
Topicort .5mg/g 1 Tube In 1 Carton > 60 G In 1 Tube
4
N N $80N$100N$80N
Topicort 2.5mg/mL 1 Bottle In 1 Carton > 100 Ml In 1 Bottle
4
N N $80N$100N$80N
Topiramate 15mg 60 Capsule, Coated Pellets In 1 Bottle
2
N N $15N$20N$15N
Topiramate 30 Capsule, Extended Release In 1 Bottle
2
N N $15N$20N$15N
Topiramate 30 Capsule, Extended Release In 1 Bottle
2
N N $15N$20N$15N
Topiramate 30 Capsule, Extended Release In 1 Bottle
2
N N $15N$20N$15N
Topiramate 30 Capsule, Extended Release In 1 Bottle
2
N N $15N$20N$15N
Topiramate 30 Capsule, Extended Release In 1 Bottle
2
N N $15N$20N$15N
Topiramate 25mg 60 Capsule, Coated Pellets In 1 Bottle
2
N N $15N$20N$15N
Topiramate 25mg 1000 Tablet, Film Coated In 1 Bottle
2
N N $15N$20N$15N
Topiramate 100mg 1000 Tablet, Film Coated In 1 Bottle
2
N N $15N$20N$15N
Topiramate 200mg 1000 Tablet, Film Coated In 1 Bottle
2
N N $15N$20N$15N
Topiramate 50mg 1000 Tablet, Film Coated In 1 Bottle
2
N N $15N$20N$15N
Toposar 20mg/mL 1 Vial, Multi-dose In 1 Carton > 50 Ml In 1 Vial, Multi-dose
2
N N $15N$20N$15N
Toprol 25mg 100 Tablet, Extended Release In 1 Bottle
4
N N $80N$100N$80N
Toprol 50mg 100 Tablet, Extended Release In 1 Bottle
4
N N $80N$100N$80N
Toprol 100mg 100 Tablet, Extended Release In 1 Bottle
4
N N $80N$100N$80N
Toprol 200mg 100 Tablet, Extended Release In 1 Bottle
4
N N $80N$100N$80N
Torisel 1 Kit In 1 Carton
3
N N $42N$47N$42N
Torsemide 20mg 100 Tablet In 1 Bottle, Plastic
2
N N $15N$20N$15N
Torsemide 100mg 12 Bottle In 1 Case > 100 Tablet In 1 Bottle
2
N N $15N$20N$15N
Torsemide 100 Tablet In 1 Bottle
2
N N $15N$20N$15N
Torsemide 100 Tablet In 1 Bottle
2
N N $15N$20N$15N
Toviaz 4mg 30 Tablet, Film Coated, Extended Release In 1 Bottle
4
N N $80N$100N$80N
Toviaz 8mg 30 Tablet, Film Coated, Extended Release In 1 Bottle
4
N N $80N$100N$80N
Tpn Electrolytes 331; 508; 1491; 2420; 321mg/20mL; mg/20mL; mg/20mL; mg/20mL; mg/20mL 25 Vial, Single-dose In 1 Tray > 20 Ml In 1 Vial, Single-dose
2
N N $15N$20N$15N
Tracleer 62.5mg 1 Bottle, Plastic In 1 Carton > 60 Tablet, Film Coated In 1 Bottle, Plastic
5
N N 33%N33%N33%N
Tracleer 125mg 1 Bottle, Plastic In 1 Carton > 60 Tablet, Film Coated In 1 Bottle, Plastic
5
N N 33%N33%N33%N
Tradjenta 5mg 90 Tablet, Film Coated In 1 Bottle
4
N N $80N$100N$80N
Tramadol Hydrochloride 50mg 100 Tablet, Film Coated In 1 Bottle
2
N N $15N$20N$15N
Tramadol Hydrochloride 300mg 100 Tablet, Extended Release In 1 Bottle
2
N N $15N$20N$15N
Tramadol Hydrochloride 100mg 30 Tablet, Extended Release In 1 Bottle, Plastic
2
N N $15N$20N$15N
Tramadol Hydrochloride 200mg 30 Tablet, Extended Release In 1 Bottle, Plastic
2
N N $15N$20N$15N
Tramadol Hydrochloride And Acetaminophen 325; 37.5mg/1; mg 1000 Tablet, Film Coated In 1 Bottle
2
N N $15N$20N$15N
Trandolapril 100 Tablet In 1 Bottle
2
N N $15N$20N$15N
Trandolapril 100 Tablet In 1 Bottle
2
N N $15N$20N$15N
Trandolapril 100 Tablet In 1 Bottle
2
N N $15N$20N$15N
Trandolapril And Verapamil Hydrochloride 100 Tablet, Film Coated, Extended Release In 1 Bottle
2
N N $15N$20N$15N
Trandolapril And Verapamil Hydrochloride 100 Tablet, Film Coated, Extended Release In 1 Bottle
2
N N $15N$20N$15N
Trandolapril And Verapamil Hydrochloride 100 Tablet, Film Coated, Extended Release In 1 Bottle
2
N N $15N$20N$15N
Trandolapril And Verapamil Hydrochloride 100 Tablet, Film Coated, Extended Release In 1 Bottle
2
N N $15N$20N$15N
Tranexamic Acid 650mg 30 Tablet, Film Coated In 1 Bottle, Plastic
2
N N $15N$20N$15N
Tranexamic Acid 100mg/mL 10 Vial, Single-dose In 1 Package
2
N N $15N$20N$15N
Transderm Scop 1mg/3d 10 Pouch In 1 Box > 1 Patch In 1 Pouch > 3 D In 1 Patch
3
N N $42N$47N$42N
Tranxene 3.75mg 100 Tablet In 1 Bottle
4
N N $80N$100N$80N
Tranxene 7.5mg 100 Tablet In 1 Bottle
4
N N $80N$100N$80N
Tranylcypromine Sulfate 10mg 100 Tablet In 1 Bottle, Plastic
2
N N $15N$20N$15N
Travasol 2.07; 1.15; 1.03; 480; 600; 730; 580; 400; 560; 68g/100mL; g/100mL; g/100mL; mg/100mL; mg/100mL; mg 2000 Ml In 1 Bag
4
N N $80N$100N$80N
Travatan Z .04mg/mL 2.5 Ml In 1 Bottle
4
N N $80N$100N$80N
Travoprost Ophthalmic Solution 0.004% .04mg/mL 1 Bottle In 1 Carton > 2.5 Ml In 1 Bottle
2
N N $15N$20N$15N
Trazodone Hydrochloride 300mg 100 Tablet In 1 Bottle
2
N N $15N$20N$15N
Trazodone Hydrochloride 50mg 500 Tablet In 1 Bottle
1
N N $5N$10N$5N
Trazodone Hydrochloride 100mg 500 Tablet In 1 Bottle
1
N N $5N$10N$5N
Trazodone Hydrochloride 150mg 100 Tablet In 1 Bottle
1
N N $5N$10N$5N
Treanda 100mg/20mL 20 Ml In 1 Vial, Single-use
3
N N $42N$47N$42N
Trecator 250mg 100 Tablet, Film Coated In 1 Bottle
4
N N $80N$100N$80N
Trelstar 22.5mg/2mL 2 Ml In 1 Vial, Single-dose
4
N N $80N$100N$80N
Trelstar 1 Kit In 1 Carton * 2 Ml In 1 Syringe
4
N N $80N$100N$80N
Trelstar 1 Kit In 1 Carton * 2 Ml In 1 Syringe
4
N N $80N$100N$80N
Tretin.x 1 Tube In 1 Carton > 35 G In 1 Tube
2
Y N $15N$20N$15N
Tretinoin 10mg 100 Capsule In 1 Bottle
2
N N $15N$20N$15N
Tretinoin 1mg/g 1 Tube In 1 Carton > 45 G In 1 Tube
2
Y N $15N$20N$15N
Tretinoin .5mg/g 1 Tube In 1 Carton > 20 G In 1 Tube
2
Y N $15N$20N$15N
Tretinoin .25mg/g 1 Tube In 1 Carton > 45 G In 1 Tube
2
Y N $15N$20N$15N
Tretinoin .25mg/g 1 Tube In 1 Carton > 45 G In 1 Tube
2
Y N $15N$20N$15N
Tretinoin 1 Tube In 1 Carton > 45 G In 1 Tube
2
Y N $15N$20N$15N
Tretinoin Gel Microsphere 1 Bottle, Pump In 1 Carton > 50 G In 1 Bottle, Pump
2
Y N $15N$20N$15N
Tretinoin Gel Microsphere 1 Bottle, Pump In 1 Carton > 50 G In 1 Bottle, Pump
2
Y N $15N$20N$15N
Trexall 5mg 30 Tablet, Film Coated In 1 Bottle
2
Y N $15N$20N$15N
Trexall 7.5mg 30 Tablet, Film Coated In 1 Bottle
2
Y N $15N$20N$15N
Trexall 10mg 30 Tablet, Film Coated In 1 Bottle
2
Y N $15N$20N$15N
Trexall 15mg 30 Tablet, Film Coated In 1 Bottle
2
Y N $15N$20N$15N
Tri Previfem 6 Blister Pack In 1 Carton
2
N N $15N$20N$15N
Tri-legest Fe 5 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
2
N N $15N$20N$15N
Tri-norinyl 6 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
4
N N $80N$100N$80N
Tri-sprintec 6 Pouch In 1 Carton > 1 Blister Pack In 1 Pouch > 1 Kit In 1 Blister Pack
2
N N $15N$20N$15N
Triamcinolone Acetonide .25mg/g 80 G In 1 Tube
2
N N $15N$20N$15N
Triamcinolone Acetonide 1mg/g 80 G In 1 Tube
2
N N $15N$20N$15N
Triamcinolone Acetonide 1mg/mL 60 Ml In 1 Bottle, Plastic
2
N N $15N$20N$15N
Triamcinolone Acetonide 5mg/g 1 Tube In 1 Carton > 15 G In 1 Tube
2
N N $15N$20N$15N
Triamcinolone Acetonide .25mg/g 1 Tube In 1 Carton > 80 G In 1 Tube
2
N N $15N$20N$15N
Triamcinolone Acetonide 1mg/g 1 Tube In 1 Carton > 80 G In 1 Tube
2
N N $15N$20N$15N
Triamcinolone Acetonide 5mg/g 1 Tube In 1 Carton > 15 G In 1 Tube
2
N N $15N$20N$15N
Triamcinolone Acetonide 1mg/g 1 Tube In 1 Carton > 5 G In 1 Tube
2
N N $15N$20N$15N
Triamcinolone Acetonide .25mg/mL 60 Ml In 1 Bottle, With Applicator
2
N N $15N$20N$15N
Triamterene And Hydrochlorothiazide 25; 37.5mg/1; mg 100 Capsule In 1 Bottle, Plastic
2
N N $15N$20N$15N
Triamterene And Hydrochlorothiazide 25; 50mg/1; mg 100 Capsule In 1 Bottle
2
N N $15N$20N$15N
Triamterene Hydrochlorothiazide 50; 75mg/1; mg 500 Tablet In 1 Bottle
1
N N $5N$10N$5N
Triamterene Hydrochlorothiazide 25; 37.5mg/1; mg 100 Tablet In 1 Bottle
1
N N $5N$10N$5N
Triazolam 10 Bottle In 1 Package > 10 Tablet In 1 Bottle
2
N N $15N$20N$15N
Triazolam 500 Tablet In 1 Bottle
2
N N $15N$20N$15N
Tribenzor 5; 12.5; 20mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N $80N$100N$80N
Tribenzor 5; 12.5; 40mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N $80N$100N$80N
Tribenzor 5; 25; 40mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N $80N$100N$80N
Tribenzor 10; 12.5; 40mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N $80N$100N$80N
Tribenzor 10; 25; 40mg/1; mg/1; mg 30 Tablet, Film Coated In 1 Bottle
4
N N $80N$100N$80N
Tricor 48mg 90 Tablet In 1 Bottle
4
N N $80N$100N$80N
Tricor 145mg 90 Tablet In 1 Bottle
4
N N $80N$100N$80N
Triderm 1mg/g 85.2 G In 1 Tube
2
N N $15N$20N$15N
Trifluoperazine Hydrochloride 2mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N $15N$20N$15N
Trifluoperazine Hydrochloride 5mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N $15N$20N$15N
Trifluoperazine Hydrochloride 10mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N $15N$20N$15N
Trifluoperazine Hydrochloride 1mg 100 Tablet, Film Coated In 1 Bottle
2
N N $15N$20N$15N
Trifluridine 10mg/mL 7.5 Ml In 1 Bottle, Plastic
2
N N $15N$20N$15N
Triglide 160mg 1 Bottle In 1 Carton > 30 Tablet In 1 Bottle
4
N N $80N$100N$80N
Trihexyphenidyl Hydrochloride 2mg/5mL 473 Ml In 1 Bottle
2
N N $15N$20N$15N
Trihexyphenidyl Hydrochloride 5mg 100 Tablet In 1 Bottle, Plastic
2
N N $15N$20N$15N
Trihexyphenidyl Hydrochloride 2mg 100 Blister Pack In 1 Box, Unit-dose
2
N N $15N$20N$15N
Trileptal 300mg 100 Tablet, Film Coated In 1 Bottle
4
N N $80N$100N$80N
Trileptal 60mg/mL 250 Ml In 1 Bottle
4
N N $80N$100N$80N
Trileptal 150mg 100 Tablet, Film Coated In 1 Bottle
4
N N $80N$100N$80N
Trileptal 600mg 100 Tablet, Film Coated In 1 Bottle
4
N N $80N$100N$80N
Trilipix 135mg 90 Capsule, Delayed Release In 1 Bottle
4
N N $80N$100N$80N
Trilipix 45mg 90 Capsule, Delayed Release In 1 Bottle
4
N N $80N$100N$80N
Trilyte 420; 1.48; 5.72; 11.2g/4L; g/4L; g/4L; g/4L 4 L In 1 Bottle
2
N N $15N$20N$15N
Trimethobenzamide Hydrochloride 300mg 100 Capsule In 1 Bottle, Plastic
2
Y N $15N$20N$15N
Trimethoprim 100mg 100 Tablet In 1 Bottle, Plastic
2
N N $15N$20N$15N
Trimipramine Maleate 30 Capsule In 1 Bottle
2
N N $15N$20N$15N
Trimipramine Maleate 30 Capsule In 1 Bottle
2
N N $15N$20N$15N
Trimipramine Maleate 30 Capsule In 1 Bottle
2
N N $15N$20N$15N
Trinessa 1 Dialpack In 1 Carton > 1 Kit In 1 Dialpack
2
N N $15N$20N$15N
Triostat 6 Vial In 1 Carton > 1 Ml In 1 Vial
4
N N $80N$100N$80N
Trisenox 1mg/mL 10 Ampule In 1 Carton
3
N N $42N$47N$42N
Triumeq 30 Tablet, Film Coated In 1 Bottle
3
N N $42N$47N$42N
Trivora 6 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
2
N N $15N$20N$15N
Trizivir 300; 150; 300mg/1; mg/1; mg 60 Tablet, Film Coated In 1 Bottle
4
N N $80N$100N$80N
Trokendi Xr 25mg 30 Capsule, Extended Release In 1 Blister Pack
4
N N $80N$100N$80N
Trokendi Xr 50mg 30 Capsule, Extended Release In 1 Blister Pack
4
N N $80N$100N$80N
Trokendi Xr 100mg 30 Capsule, Extended Release In 1 Blister Pack
4
N N $80N$100N$80N
Trokendi Xr 200mg 30 Capsule, Extended Release In 1 Blister Pack
4
N N $80N$100N$80N
Trophamine .54; 1.2; .32; .024; .5; .36; .48; .82; 1.4; 1.2; g/100mL; g/100mL; g/100mL; g/100mL; g/100mL; g/100 6 Carton In 1 Case > 1 Container In 1 Carton > 500 Ml In 1 Container
3
N N $42N$47N$42N
Trophamine .32; .73; .19; .02; .3; .22; .29; .49; .84; .69; .g/100mL; g/100mL; g/100mL; g/100mL; g/100mL; g/100 12 Carton In 1 Case > 1 Container In 1 Carton > 500 Ml In 1 Container
3
N N $42N$47N$42N
Trospium Chloride 20mg 60 Tablet, Film Coated In 1 Bottle
2
N N $15N$20N$15N
Trospium Chloride 60mg 30 Capsule, Extended Release In 1 Bottle, Plastic
2
N N $15N$20N$15N
Trulicity 4 Syringe In 1 Carton
4
N N $80N$100N$80N
Trulicity 4 Syringe In 1 Carton
4
N N $80N$100N$80N
Trusopt 20mg/mL 1 Bottle, Dropper In 1 Carton > 10 Ml In 1 Bottle, Dropper
4
N N $80N$100N$80N
Truvada 200; 300mg/1; mg 30 Tablet, Film Coated In 1 Bottle, Plastic
3
N N $42N$47N$42N
Twinrix 720; 20[iU]/mL; ug/mL 10 Vial In 1 Carton
6
N N $0N$0NNAN
Twynsta 5; 40mg/1; mg 3 Blister Pack In 1 Carton > 10 Tablet, Multilayer In 1 Blister Pack
4
N N $80N$100N$80N
Twynsta 10; 40mg/1; mg 3 Blister Pack In 1 Carton > 10 Tablet, Multilayer In 1 Blister Pack
4
N N $80N$100N$80N
Twynsta 5; 80mg/1; mg 3 Blister Pack In 1 Carton > 10 Tablet, Multilayer In 1 Blister Pack
4
N N $80N$100N$80N
Twynsta 10; 80mg/1; mg 3 Blister Pack In 1 Carton > 10 Tablet, Multilayer In 1 Blister Pack
4
N N $80N$100N$80N
Tybost 30 Tablet, Film Coated In 1 Bottle
3
N N $42N$47N$42N
Tygacil 50mg/5mL 10 Vial, Single-use In 1 Carton
4
N N $80N$100N$80N
Tykerb 250mg 150 Tablet In 1 Bottle
5
N N 33%N33%N33%N
Tylenol With Codeine 300; 30mg/1; mg 1000 Tablet In 1 Bottle
2
N N $15N$20N$15N
Tylenol With Codeine 300; 60mg/1; mg 500 Tablet In 1 Bottle
2
N N $15N$20N$15N
Typhim Vi 25ug/.5mL 1 Vial, Multi-dose In 1 Package
6
N N $0N$0NNAN
Typhim Vi 1 Syringe In 1 Package
6
N N $0N$0NNAN
Tysabri 300mg/15mL 1 Vial, Single-use In 1 Carton > 15 Ml In 1 Vial, Single-use
5
N N 33%N33%N33%N
Tyvaso 1.74mg/2.9mL 4 Ampule In 1 Box > 2.9 Ml In 1 Ampule
4
Y N $80N$100N$80N
Tyzeka 600mg 30 Tablet, Film Coated In 1 Bottle
4
N N $80N$100N$80N



Medicare Help's Additional Notes:

Coverage Levels for H2150-002

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1.Pre-Deductable: Before you reach the plans deductible of $0. Some plans offer select Pre-deductible drug Coverage
2.Initial Coverage: (ICL) After you reach the plans deductible but before the Initial Coverage limit of $3700
3.Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $4950 in 2017.
4.Catastrophic: Anything over $4950 you will receive a significant increase in coverage.

Definitions:

Premium: A monthly flat fee that varies by plan.
Deductible: The amount you must pay each year for your prescriptions before your plan begins to pay its share of your covered drugs. The max in 2017 is $320. Some plans have a $0 Deductible.
Tier Level: Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less.
Quantity Limit Amount/Days: Certain drugs have a Quantity Limit. That means the plan will only cover the drug up to a designated quantity or amount. If your prescribing doctor feels it is necessary to exceed the set limit, he or she must get prior approval before the higher quantity will be covered.
Prior Authorization: Certain Drugs require you or your doctor to get prior authorization in order to be covered. Usually just an additional form. If you dont get approval, the plan may not cover the drug.
Does the Deduct Apply: Some drugs do not require that the deductible is met before you receive coverage.
Step Therapy: Means you must first try one drug to treat your medical condition before the plan will cover another drug for the same condition. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Cost Prefered: Your Cost for the Drug at the Providers In Network Prefered Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non Pref: Your Cost for the Prescription Drug at a Non-Prefered Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Mail: Your Cost for Prescription Drugs through a Mail Order Pharmacy. As a Percent of the total drug cost or a flat rate.


What if a drug I need is not listed?

Please check the formulary for different brand and generic names. If you still cannot locate your drugs, your plan may not offer coverage. Talk to your doctor first about changing your prescription to a drug on your plans formulary. If this is not an option, you can request an exception to have the plan review its coverage decision based on your individual circumstances.

Source:CMS Formulary Data Oct. 2016
Source:NDC Directory by FDA.gov

**We make every attempt to keep our information accurate. But please check with the plan providers to verify all information.

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